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The Controversial areas of billing and coding for Podiatry

November 17, 2016

The Podiatry revenue management has always been in controversy due to the medical necessity requirements from various insurance carriers and Medicare. Most of these insurance carriers reimburse for the treatment of conditions of foot and not its preventive care. For example, foot care without any visible symptoms is not covered by the insurance carriers. This has led to greater confusion and difficulties in treatment and CPT coding of foot conditions.

Payment Trouble for Nail Debridement

According to insurancenewsnet.com, Medicare unseemly paid around $96.8 million for nail debridement and related podiatry medical billing services. The claims for Nail debridement was almost a quarter of the entire Medicare payments to podiatrists, and out of the $1 billion that was paid to podiatrists, $234 million were paid for nail debridement; where $96.8 million of it was paid improperly, and 23% of the carriers at that time had no medical justification. In order to control this weird situation, Medicare generated certain Podiatry medical billing guidelines and rules relating to foot care that one needs to follow continuously for CMS to acknowledge the claim.

Non-covered benefit for foot care

Non- covered benefit includes routine foot care which does not show any symptoms. For example, coverage of plantar keratosis, corns, calluses, bunions, nails and other maintenance care for bed-confined or ambulatory patients comes under routine care, which is not covered. Although there are situations, like in the case of foot care for precise conditions, that result in thrombophlebitis, sensory loss, the systemic disease needs to be of acute severity whose non-professional treatment could be risky for the health of the patient.

While there are services like routine foot care that Medicare doesn't cover, there are few specifications or exceptions that can be of benefit. These include:

Systemic diseases like neurologic, vascular or metabolic when encountered in routine foot care which can put the patients' health at risk.

Just like the services provided for treatment of warts on any part of the body, warts on the foot can be covered under the insurance.

Services termed as routine if done as a necessary or integral part of otherwise covered services like ulcers, wounds and infections.

Under the exceptions to the routine foot care exclusion, treatment of mycotic nails may be covered.

Unlike a physician's care, Medicare covers an evaluation of the foot care once in six months if the patient is diagnosed for loss of protective sensation and diabetic sensory neuropathy. Reporting of this condition requires a patient's history, a physical examination conducted, examination of vascular status and the patient's education.

HCPCS codes G0245 (initial service) and G0246 (follow-up service) should be reported. Code G0247 may be reported on the same date if the physician also performs routine foot care including local wound care, trimming and debridement of nails, and debridement of corns and calluses. The following diagnosis codes should be reported in synchronization with this benefit: 250.60, 250.61, 250.62, 250.63 and 357.2.

There are many ups and downs to services provided by a podiatrist physicians confining in foot care, or a general practitioner treating conditions of the foot and ankle. Because of these special Podiatry billing guidelines, it is important for practices to know and understand what will be covered by insurance and what the patient will be responsible for, so that you get the deserved payment from the responsible party. It is also essential to understand the services themselves to choose the appropriate codes for reimbursement, and special instructions on the completion of the CMS-1500 form for some foot care procedures.To obtain hassle free reimbursement from responsible party or insurance companies, it is good option to hire professional medical billing agency. They have trained staff of medical billers as well as save your money invested on in-house billing.

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